Global migration and factors influencing retention of Asian internationally educated nurses: a systematic review

Background Given nurses’ increasing international mobility, Asian internationally educated nurses (IENs) represent a critical human resource highly sought after within the global healthcare workforce. Developed countries have grown excessively reliant on them, leading to heightened competition among these countries. Hence, this review aims to uncover factors underlying the retention of Asian IENs in host countries to facilitate the development of more effective staff retention strategies. Methods A mixed-methods systematic review was conducted using the Joanna Briggs Institute methodology for mixed-method systematic review. A search was undertaken across the following electronic databases for studies published in English during 2013–2022: CINAHL, Embase, PubMed, Scopus, Web of Science and PsycINFO. Two of the researchers critically appraised included articles independently using the Joanna Briggs Critical Appraisal Tools and Mixed Methods Appraisal Tool (version 2018). A data-based convergent integrated approach was adopted for data synthesis. Results Of the 27 included articles (19 qualitative and eight quantitative), five each were conducted in Asia (Japan, Taiwan, Singapore and Malaysia), Australia and Europe (Italy, Norway and the United Kingdom); four each in the United States and the Middle East (Saudi Arabia and Kuwait); two in Canada; and one each in New Zealand and South Africa. Five themes emerged from the data synthesis: (1) desire for better career prospects, (2) occupational downward mobility, (3) inequality in career advancement, (4) acculturation and (5) support system. Conclusion This systematic review investigated the factors influencing AMN retention and identified several promising retention strategies: granting them permanent residency, ensuring transparency in credentialing assessment, providing equal opportunities for career advancement, instituting induction programmes for newly employed Asian IENs, enabling families to be with them and building workplace social support. Retention strategies that embrace the Asian IENs’ perspectives and experiences are envisioned to ensure a sustainable nursing workforce. Supplementary Information The online version contains supplementary material available at 10.1186/s12960-024-00900-5.


Background
Nurses constitute more than half of the global healthcare workforce and are integral to providing patient treatment and ensuring continuity of care [1].The World Health Organization has estimated that there is already a shortage of 5.9 million nurses before the 2019 coronavirus disease (COVID-19) pandemic [2].Amidst this shortage, internationally educated nurses (IENs) have proved to be a critical resource for healthcare systems worldwide.According to the State of the World's Nursing Report 2020 by the World Health Organization, nurses' international mobility is increasing-one in every eight nurses practises in a foreign country [3].In this regard, Asian IENs, originating mainly from the Philippines and India [4], represent a significant proportion of the migrant healthcare workforce in developed countries, such as Australia [5], New Zealand [6], the United Kingdom [7] and the United States [8], which highlights these countries' reliance on foreign-trained nurses.Nonetheless, migration is no simple task [9]: Asian IENs must leave their comfort zone and face challenges in immigration, credentialing, and differences in cultures, clinical practices and values [10].However, such difficulties have not deterred their migration across host countries.A segment of New Zealand-based Asian IENs have been reported to consider nursing prospects abroad for future career development [11].Asian IENs also migrate within Asian countries before transitioning to countries such as the United States and the United Kingdom.Therefore, such occurrences have presented a situation where some Asian countries, such as Singapore and Malaysia, have become transit country for Asian IENs seeking further migration [11].In particular, Singapore is a valuable stepping stone for these Asian IENs who migrate to other host countries [12].This is supported by reports which cited that 14.8% of the Asian IENs in Singapore left the public sector workforce in 2021 [13].
In the era of globalisation, the escalating demand for nurses demonstrated and exacerbated by the COVID-19 pandemic has endowed Asian IENs with greater autonomy in deciding their places of practice.Countries such as Germany, the United Arab Emirates, the United Kingdom and Singapore have introduced various strategies to recruit IENs, such as providing fair wages, free travel, language training, and incentives for passing licensure examinations, easing the recognition of foreign professional qualifications; and expediting visa approvals [14][15][16].Thus, these strategies have prompted an influx of IENs from their countries of origin or other developed countries where they work.
While international recruitment may represent a quick-fix option, healthcare systems experiencing excessive out-migration of their IENs should address their retention effectively.This perspective is critical given the substantial costs associated with high turnover [17].Besides economic effects, rapid staff turnover can cause unfamiliarity among staff members in the interprofessional group and affect interprofessional collaboration, leading to negative patient outcomes.The likely adverse patient outcomes include increased patient falls, incidences of pressure ulcers, the average length of patient stay, and medication errors [18].Consequently, countries should strategise to ensure the sustained retention of their Asian IENs to mitigate rapid turnover and continue international recruitment.
Many studies have investigated IENs' lived experiences about aspects such as transition [19], integration [20] and resilience [21].Although such general experiential insights are valuable, only one review by Pressley et al. [21] has specifically examined the experiences of IENs employed in different countries to provide knowledge on their retention in an overseas position.However, they limited the scope of their review to studies that focused on five developed countries and used qualitative research designs, with most such studies characterising only the initial migratory stages.Thus, there is a gap in knowledge regarding the experiences related to the long-term retention of IENs.
Notably, the experiences of Asian IENs have not been explored in any systematic reviews.Further, despite being the continent with the largest suppliers of nurses, Asia registers the lowest density of nurses worldwide.Many high-income countries rely excessively on IENs due to their inadequate domestic supply or the worsening of their shortages induced by the COVID-19 pandemic [3].Given the increasing demand for nurses and a depleting supply (suboptimal retention), countries conventionally inactive in international recruitment have begun turning to Asian IENs to fill their vacancies [22].The resultant escalating competition between countries for IENs, coupled with the ever-growing global shortage of nurses, underscores the urgency to retain the current strength of this workforce.To this end, this systematic review of Asian IENs offers a critical examination of factors influencing their retention in host countries, in line with which the relevant authorities can formulate strategies to ensure a sustainable healthcare workforce.

Methods
In this systematic review, we adopted the Joanna Briggs Institute (JBI) methodology for mixed-methods systematic reviews through a data-based convergent integrated approach [23].

Search strategy
A preliminary search was performed on PubMed and Embase to identify relevant articles.Words in the titles and abstracts of identified articles were used to formulate a comprehensive search strategy with an experienced librarian from the Medical Library for guidance.Key search terms included ' Asian migrant nurses' , 'retention' and 'experience' .Then, a second comprehensive electronic search was performed across CINAHL, Embase, PubMed, Scopus, Web of Science and PsycINFO.The search terms and strategies for each database are provided in Additional file 1.The references of all identified studies were also screened for additional relevant studies.As per the eligibility criteria (see Table 1), studies published in English during 2013-2022 were included.A bibliography management software, EndNote X9 [24], was used to import all the studies and remove duplicates.The titles and abstracts were screened independently by two reviewers (DU and RP) against the inclusion criteria.The selection process is illustrated in a PRISMA flow diagram (Fig. 1).

Study selection
Eligible articles were retrieved in full and reviewed.Two reviewers (DU and RP) independently used a standardised data-extraction template to extract the following study details: author(s), year of publication, country, study aim(s), methodology, sample characteristics, themes, and primary findings pertinent to the review question.Differences were resolved through discussion with a third reviewer (SYL).

Assessment of methodological quality
The JBI checklists for analytical cross-sectional studies [25] and for qualitative research [26] were used to appraise quantitative and qualitative studies, respectively [27].The methodological quality of each study was rated as low (0-49%), medium (50-75%) or high (75-100%).Two reviewers (DU and RP) performed separate critical appraisals.The research team resolved any discrepancies in appraisals through discussions.All studies were included, regardless of their methodological rating (see Tables 2, 3), to ensure that all available evidence could be integrated to maximise the understanding of factors influencing Asian IENs retention.

Data extraction and synthesis
A data-based convergent synthesis was undertaken using the JBI approach to mixed-methods systematic reviews, during which the results of the included quantitative and mixed-methods studies were transformed into qualitative findings.Under this design, the data were analysed using the same synthesis method and combined and synthesised [28].A three-step thematic synthesis proposed by Thomas and Harden [29] was performed.First, the texts were inductively coded; second, the resultant codes were compared and organised into categories to form 'descriptive themes'; and, last, these themes were re-read and compared with evidence from the textual data of the included studies independently by two reviewers to generate 'analytical themes' .
Next, the themes were finalised after a consensus was reached between the two independent reviewers (DU and RP), with arbitration by a third reviewer (SYL) when required.

Search outcomes
Our database search yielded 2003 records, of which we removed 759 duplicates.The remaining 1244 articles were subjected to title-and abstract screening, after which 1145 were deemed irrelevant.The full texts of the     remaining 78 articles were assessed for eligibility, leading to the final inclusion of 27 studies (Fig. 1).

Study characteristics
The 27 studies (19 qualitative and eight quantitative) comprised five each from Asia (Japan, Taiwan, Singapore and Malaysia), Australia and Europe (Italy, Norway and the United Kingdom); four each from the United States and the Middle East (Saudi Arabia and Kuwait); two from Canada; and one each from New Zealand and South Africa.The study characteristics and findings are outlined in Table 4.The studies collectively exhibited a mediumto-high methodological quality, as demonstrated by their overall ratings that ranged from 60 to 100%.Of note, our thematic synthesis yielded five themes-all of which were not country-specific and could be transferable between the geographical settings-as follows: (a) desire for better career prospects; (b) occupational downward mobility; (c) inequality in career advancement; (d) acculturation; and (e) support system.

Theme 1: Desire for better career prospects
The most prevalent theme was Asian IENs' search for better career prospects, on which 15 studies reported relevant findings.The factors that motivated Asian IENs to migrate were economic, work-related, and personal.As for the first factor, seven studies emphasised the role of economic factors, citing nurses' desire to attain a better socio-economic position than that in their home country [30][31][32][33][34][35][36].The specific reasons underlying the push factors for Asian IENs to leave their current host countries were the deteriorating exchange rate of the current host country [37], the unfair, discriminatory remuneration practices based on nationality [38], and the declining pay when compared with that in more affluent host countries [39].
Regarding work-related factors, three studies highlighted factors such as poor career paths, a lack of opportunities, a heavy workload and the poor public perception of nurses [34,36,37]; these factors also drove Asian IENs to search for better prospects in other countries.In addition, four studies reported that when Asian IENs' professional autonomy was improved, they preferred continuing in their existing jobs [38][39][40][41].In contrast, two studies found that organisational responsibilities negatively influenced their turnover intention [32,42].Last, personal factors, such as nurses' desire to travel and experience different cultures and lifestyles, were identified in four studies [33,39,41,43].

Theme 2: Occupational downward mobility
Occupational downward mobility undermined the retention of the Asian IENs, as highlighted in nine studies.Six studies reported that Asian IENs faced difficulties in credentialing assessments and recognition by local nursing regulatory bodies [30,33,34,40,44,45]: the process was not only complex and time-consuming [30,45] but also lacked transparency [34,40].Moreover, they experienced difficulty passing nursing licensure and language competence examinations [30,34,45].Importantly, these nurses were subjected to occupational downgrading; since they were often relegated to a role lower than that of a registered nurse, pending completion of their recognition, this relegation resulted in their deskilling [30,34,40,45].In addition, education levels were a determinant of their career satisfaction, with diploma holders being the most satisfied, followed by bachelor-degree holders and higher-degree holders in that order [46].
As reported in eight studies, disparities between the Asian IENs' expectations and reality represented another critical aspect.Five studies highlighted that differences in nursing practices could influence their retention.For example, in developing countries such as China, Indonesia, and the Philippines, patients' families often perform basic nursing care (e.g.feeding, personal cleanliness, dressing, and elimination).Conversely, in developed countries, Asian IENs would be expected to undertake such activities for patients [30,33,39,41,42].Moreover, the remaining three studies reported a similar disparity for Asian IENs employed in either long-term care facilities (where the scope of practice might be limited) or other incongruous settings (where their previous experiences or expertise might be irrelevant), with resultant deskilling among them [37,42,47].Similarly, Primeau et al. [47] have corroborated that Asian IENs in long-term care facilities exhibited lower career satisfaction than their hospital-based counterparts.Such disparities have led to frustration and disempowerment among Asian IENs and compromised their retention [32,37].

Theme 3: Inequality in career advancement
Seven studies suggested that inequality in opportunities for career advancement compromises Asian IENs' retention.Four studies identified a lack of access to advanced education [33,34,48,49].The remaining three reported a lack of organisational or leadership responsibilities [34,37,48] as a cause of limited career progression.Furthermore, Nursalam et al. [33] highlighted unclear career pathways.The Asian IENs also reported that they were given fewer opportunities for career development than host-country nurses [38,46].Last, an unfair performance appraisal system and a nationality-based remunerative system were found to be predictors of turnover [38].

Theme 4: Acculturation
Acculturation and its various aspects critically influenced the Asian IENs' retention, as demonstrated in 13 studies.Sociocultural adaptation correlated positively with the Asian IENs' career satisfaction [35] and retention [50], but ten studies highlighted that communication barriers hindered their acculturation.The challenges they faced were manifold.For instance, they needed to learn a new language [33,42,45]; their communication skills were inadequate [40,51]; they found it challenging to understand informal language [39,41]; they were unfamiliar with local accents and were unable to cope with the communication speed of those who used the local language [41,51]; and they were unfamiliar with dialects [35,41].Furthermore, four studies underlined the role of English proficiency in affecting career satisfaction [35,44,51,52].
As with languages, cultural identity is socially constructed.Difficulties in acculturation due to deep-rooted cultural beliefs upheld by Chinese [41], Indian [40,53] and Japanese migrant nurses [43] have been documented.Moreover, cultural distance-a collective term denoting differences in religious beliefs, ethnicity, social norms, and languages-predicts the Asian IENs' retention, as shown in four studies [31,35,44,52].Nonetheless, some encouraging evidence has suggested that Asian IENs employed in Asian countries could acculturate more rapidly than those employed in non-Asian countries [31,35,44,52].

Theme 5: Support system
The lack of a support system for Asian IENs and the concomitant isolation from family support structures/ systems were identified in seven studies to correlate negatively with their retention.In the physical absence of their family [40,45,49,53], the Asian IENs' continuous remote engagement with their family promoted their emotional stability, thereby contributing to retention [42,54].Similarly, providing visas or contracts to their spouse and children positively influenced their retention [37,38,48].Moreover, Almansour et al. [49] reported that Asian IENs in Saudi Arabia with 'married-status' contracts, which provide accommodation, hospitalisation coverage and air tickets for their families, had higher satisfaction levels than their counterparts with 'single-status' contracts.
Further, seven studies suggested that social support from an immediate supervisor favoured the Asian IENs' retention [40,45,49,53].Using the Anticipated Turnover Scale, Alshareef et al. [38] found such support to be a significant predictor of anticipated turnover.Thus, creating a supportive work environment is crucial since wholesome collegial interactions likely reduce workplace stress and promote physical and psychological well-being [42,44].Notably, perceived stress impaired not only sociocultural adaptation [35], but also job satisfaction [50], resulting in calls for stress-management programmes [50].

Discussion
Our synthesis of 27 articles through a systematic review uncovers insightful existing knowledge about the underlying factors influencing Asian IENs' retention in their host countries, in line with which the relevant authorities can devise retention strategies.Our thematic analysis demonstrated that, across the included articles, the Asian IENs' search for better career prospects emerged as the most prevalent theme.Asian IENs, motivated to attain a higher social and economic standing, migrate with high expectations in pursuit of enhanced remuneration to improve their socio-economic position and provide a better future for their families via remittances [32].While economic factors may predominate in the Asian IENs' consideration, these are not the sole impetus.Work-related factors, such as more attractive opportunities for career advancement and further education, also drive them to migrate out of their current host countries.In addition, the Asian IENs anticipate a favourable working environment that would provide them with societal respect, a low workload, autonomy and better career paths [34].Personal factors, such as the search for a better quality of life, have also spurred nurses from China, Japan and Singapore to explore different lifestyles abroad [41,43].
Overall, the common denominator across all such factors is the Asian IENs' constant desire to seek destinations with better opportunities, given the ease of international mobility [55].For example, in the Philippines-Singapore 'bus-stop' migration model, Filipino nurses build their skill sets and experiences in Singapore and then attempt to move to other countries that more readily grant permanent residency [12].Accordingly, the implication is that policymakers need to acknowledge the phenomenon of such mobility and provide direct pathways to secure long-term settlement and retention of Asian IENs in host countries, such as offering them permanent residency and professional advancement.
Moreover, occupational downward mobility is another theme that contributes to the Asian IENs' turnover.During their transition, they face challenges that lead to their deskilling: delays in assessments and recognition of their nursing credentials [34], devaluation of their previous nursing qualifications during accreditation [44], difficulty in passing nursing licensure and language-competence examinations [45]; and relegation, either to a role with a job scope inferior to that of a registered nurse or to areas not matching their previous experiences [47].Consequently, this finding calls for greater transparency in the credential requirements for acquiring a nursing practice licence in host countries and the accessibility towards recognising nursing credentials from the country of origin (e.g. the duration of application) [40].To promote transparency in accreditation across borders, universal referential systems, such as the European Qualifications Framework, which relates different countries' national qualifications systems to a common European reference standard, can be adopted [56].
Another aspect under this theme is the disparities between the Asian IENs' expectations and reality.Although they possess credentials similar to that of local nurses [34], most Asian IENs are placed in settings not commensurate with their previous education or expertise, resulting in their deskilling [30].Asian IENs with higher educational qualifications exhibited lower job satisfaction [46].This finding highlights the need for flexible bridging programmes initiated at the organisational level to match their competencies and qualifications to their new places of practice [34].Other mismatches are also notable.For instance, Asian IENs recruited into long-term care facilities may have a limited scope of practice [57] since they originate from countries where nursing homes and care homes might be less prevalent.Thus, they may find themselves entering employment with a warped understanding of the job scope [42,47].Furthermore, in countries such as China, Indonesia and the Philippines, families often deliver basic nursing care to patients in the wards of tertiary hospitals [30,41,42]; however, in some Asian IENs' host countries, the nursing staff is expected to provide such care.Such discordance between job expectations and existing care delivery practices may contribute to feelings of devaluation and disempowerment among Asian IENs.Accordingly, organisations need to adopt recruitment approaches that detail the nursing job scope in the prospective applicants' native language so that they can make informed decisions before migrating [33,37,47].
Inequality in career progression, the third theme evident in this review, represents an unspoken perception among Asian IENs.Compared with host-country nurses, Asian IENs reported fewer opportunities for career advancement, fewer opportunities for further education, a lack of organisational responsibilities and a restricted scope of practice due to deskilling [37,49].In this context, it is critical to acknowledge the importance of professional development as a principal pull factor for migration by Asian IENs.To address this implicit but critical perception, organisations should be transparent with Asian IENs' prospects of career progression at the early stage of their career [37,42,49].
Acculturation-the fourth theme we identified in this review-is the psychological adjustment Asian IENs undergo on migrating across geographical borders.Significantly, individuals' interpretation of a social environment provides an orderly, common-sense process of which they are unaware [58].This process is shaped by the individuals' language and ethnicity and how they maintain their culture in public and private settings [50].Within this context, communication styles are influenced by communication speeds, informal language, accents, intonation, dialects, and colloquial terms established through longstanding usage.Hence, these communication styles are intricately nuanced and highly contextual [39,40].As language is a social construct, and by providing advanced language training can improve Asian IENs' intercultural communication [39,51] and facilitate the ease of acculturation [50].
We observed that nurses who migrate to countries with a shorter cultural distance demonstrate accelerated cultural adaptation, such as Asian IENs who move to another Asian country [31,52].This finding highlights the need for healthcare organisations to consider cultural distance before recruitment.Multiple studies have emphasised the importance of a robust orientation programme for the Asian IENs' smooth integration into the host country's social system [32,48,54,59].Corroborative evidence has also been provided by Redman et al. [60], who reported a negative correlation between nurses' perceived quality of orientation efforts and turnover intention.In this context, orientation regarding culture and social norms should be bilateral to facilitate mutual respect and empathy for cultural differences [35].In addition to cultural orientation, studies have identified the need for an induction programme for successful longterm adaptation [32,40,44,48,60], under which strategies include pairing the Asian IENs with local nurses [44] or with host nurses from similar cultures [40].
A robust support system-the fifth theme that our review revealed-has been identified as a crucial determinant in acclimatising Asian IENs.Amidst struggles with loneliness and homesickness [49,53], Asian IENs must build a social network from scratch and familiarise themselves with their host country's local social activities and norms [39,45].Within this context, their families play a part in mitigating their isolation, and this familial presence contributes to their sustained retention [61].Notably, married Asian IENs with children were more satisfied than those without [46,49], which might be attributed to the positive association between familylife satisfaction and job satisfaction [62].Thus, given the mitigating role of the Asian IENs' families, the implication of this finding at the national level is to give Asian IENs married-status contracts and issue visas to their next of kin, contributing to the sustained retention of Asian IENs.
Likewise, a social network independent from families is important to curb isolation.Upon settling into a culturally different environment, the Asian IENs must rebuild a local social network [39,45].Hence, organisations should introduce regular social gatherings involving all staff to promote a sense of belonging among the Asian IENs [35,39,41].Through undergoing and sharing everyday experiences, relatable conversational topics can be initiated to accelerate acculturation and mitigate isolation [45].This process can be further enhanced if the Asian IENs integrate into the local community by aligning themselves with similar cultures and languages [37,44].
Last, supportive supervision, strong leadership from immediate supervisors, and interpersonal relationships are critical in promoting a positive work environment for Asian IENs [38].In addition, healthcare institutions should implement culturally appropriate stress-management programmes as part of an organisational health promotion strategy [59].In particular, acculturation extends beyond the initial orientation stage.A comprehensive support system implemented from the individual to the organisational level will enable successful longterm adaptation by Asian IENs [35].Following the easing of onboarding stressors, such as language barriers, alienation, and culture shock, the Asian IENs are envisioned to establish better communication skills and build their social networks, thereby contributing to their sustained retention.

Strengths and limitations
This review has included studies across settings with different cultural and social constructs, encompassing not only Asian and non-Asian host countries, but also developed and developing countries.This strength provided a differentiated examination of Asian IENs across the various themes.Nonetheless, some significant limitations remain.For example, some included studies focused solely on career satisfaction instead of turnover intention.However, career satisfaction and turnover intention are likely correlated [63].Further, the reviewed studies did not explore migratory patterns and their associated implications post-COVID-19.In addition, grey literature and non-English publications were excluded from this review.

Implications for administrators
This review offers an analysis of the factors influencing the retention of Asian IENs in host countries, which healthcare organisations can use as a basis to develop staff retention strategies and evaluate their turnover rates.First, given the Asian IENs' international mobility and migratory options, host-country healthcare organisations should ensure that these individuals' intrinsic and extrinsic motivations are met, especially regarding granting permanent residency.Second, healthcare organisations should comprehensively detail the nursing practice environment and job scope during their recruitment efforts, while nursing regulatory bodies should ensure transparency in credentialing assessment and recognition to avoid mismatches between reality and Asian IENs' expectations and, thus, prevent their disillusionment.Third, healthcare organisations should ensure equality and transparency in communicating career advancement prospects and further education opportunities.Fourth, with due consideration of cultural distance, healthcare organisations should institute differentiated orientation and induction programmes that are more sensitive to the cultural needs of the Asian IENs to help them adapt more effectively to the new environment.Next, robust support systems should be in place to facilitate Asian IENs' social integration, during which their new local social network and family support are critical.To further promote their sustained retention in host countries, policymakers may also consider providing visas and contracts to their families.Finally, healthcare organisations should cultivate a wholesome working environment by upholding supportive supervision and solid collegial relationships.

Conclusion
In this systematic review, we have thematically explored the factors influencing the retention of Asian IENs in host countries.Studies on their motivations and expectations have revealed that Asian IENs' constant search for better career prospects drives them to migrate.However, upon employment in the host countries, they face occupational downgrading in the profession, leading to their deskilling and mismatched expectations; moreover, they experience inequality in career progression.They also face further challenges in the acculturation stage; it has been found that during this stage, a robust support system and positive interpersonal relationships expedite their sociocultural adaptation.Our review has also identified potential strategies for policymakers to retain Asian IENs.Although increasing the number of recruitments drives to address nursing shortages may represent a quick solution, policymakers should avoid such a myopic outlook: they should address the root causes of high turnover and re-evaluate the efficaciousness and sustainability of their existing staff retention measures.Future research may explore downstream factors influencing Asian IENs' retention, such as adverse working conditions, burnout or challenges faced by specific vulnerable groups, to provide more targeted solutions to issues concerning the retention of Asian IENs.
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Table 1
Selection criteria for the studies

Table 2
JBI critical appraisal checklist for analytical cross-

Table 4
Characteristics of Included Studies